双轨病历构建

Construction of Dual Track Medical Record

医学实践内容不断扩展,以身体哲学为基础的人文医学进路逐渐清晰,现有标准化病历却没有人文医学空间,需要重新构建双轨病历。双轨病历包含人文医学实践与生物医学实践,是病历管理模式的必然方向。双轨病历的记录内容、记录方式,将成为医学现阶段的一个重要研究课题。在分析生物医学病历书写与叙事医学病历书写之后,全面设计双轨病历,目的是使人文医学与生物医学的实践有机相融,完整、全方位记录全人医学实践。实现双轨病历的关键基础是借助信息技术,利用人文医学本体,智能化记录医学实践是未来的发展方向。

Along with continuous exploration in medical practice contents,the approach of humanistic medicine based on body philosophy becomes distinct.Present standard medical record leaves no space for humanistic medicine,so it is necessary to reconstruct the dual track medical record.Dual track medical record includes humanistic medicine practice and biomedical practice,which is an inevitable direction for medical record management mode.The recording content and recording mode are important research topics at present.After analyzing the writing of biomedical medical record and narrative medical record,the writer comprehensively designs the dual track medical record in order to fully blend the practice of humanistic medicine and biomedicine,and to record the whole person's medical practice in a complete and all-round way.The key basis of dual track medical record is information technology.Its future development lies in smart medical recording mode based on humanistic medicine.